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San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 24498 N LOWER SACRAMENTO Rd PERMITWP#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> �-Contraclor Name:Cascade Drilling, LP <br /> --enw#: 1058833336 Expiration Date:9/30/2021 <br /> Signature: Title: Estimator <br /> Print Name: Rick AlCartado Date:4/15/20 <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following diolarations:(check one) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation,as <br /> G provided for by Section 3700 of the Labor Code,for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the <br /> 13 Labor Code,for the performance of the work for which this permit is issued.My workers' <br /> compensation insurance caner and policy numbers are: <br /> Carrier:Ace American Ins Comp Policy#.wlrc65890252 Esp.Data: 11/1/20 <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers compensation law of California,and agree that if I <br /> should become subject to workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Signature: <br /> Print Name: Rick alcartado <br /> aRNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> Rick Alcartado .. ,hereby authorize )ames Robinson of Enviro Assessment <br /> to sign this San Joaquin County Well&Boring Permit Application on my behalf.I understand this <br /> authorization is valid for one year and is limited to the workplan dated on the front page of this application. <br /> EHn 2MI 5-13017 Sib MW,A.n We11,HorInB pmmN Appllwtlon <br />